Update on the Health and Behavior Assessment and Intervention CPT® Codes

by Government Relations Staff

July 26, 2004 — Effective January 1, 2002, the American Medical Association’s Current Procedural Terminology (CPT)® Manual contained new billing codes designed to capture behavioral services provided to patients to address physical health problems. The introduction of the health and behavior assessment and intervention codes, and their acceptance by the Federal Medicare program, marked years of work by the American Psychological Association Practice Organization (APAPO) and its members to advance the concept of psychologists as practitioners whose knowledge can help patients deal with physical as well as mental health issues.

The first year of implementation was a time of transition, with much work being done by our members and APAPO to ensure that Medicare carriers were properly reimbursing psychologists for health and behavior services. Now with Medicare carriers across the country reimbursing for the codes, our focus has shifted to expanding coverage by private insurance. We are distributing this information to provide you with an update on the status of the codes.

Medicare Coverage of the Codes

There are six health and behavior codes, two for assessment procedures and four that reflect intervention services. There is one code for the initial assessment of the patient and another for a reassessment. The intervention codes are for services with an individual, a group, a family including the patient, and a family without the patient present.

From the beginning, Medicare agreed to cover five of the six codes (The exception is the family intervention without the patient, because Medicare covers only services provided to beneficiaries). Translating policy into practice, however, did not happen automatically. Some problems were simply technical ones as local Medicare carriers needed to update their computer software in order to recognize the new codes. In other situations, however, there was a lack of understanding about the codes that required coordinated advocacy to the carriers.

Throughout 2002, representatives of the State Psychological Associations (SPAs) and the Centers for Medicare and Medicaid Services (CMS) worked along with APAPO to ensure that Medicare carriers were reimbursing for services under the codes. CMS staff at both the national and regional levels interceded when one carrier mistakenly concluded that the codes represented preventive medicine services and therefore were not eligible for coverage.

APAPO reviewed a number of denied claims and found that some carriers did not realize a psychologist could treat patients who had been diagnosed with a physical, rather than a mental, health problem. To educate the carriers, representatives from the SPAs took part in telephone calls and face-to-face meetings with carrier medical directors and their staff. When necessary, outreach by the SPAs was followed by correspondence from APAPO, contesting the reasons why psychologists were being denied reimbursement. The problems were resolved and Medicare carriers across the country are now paying for services under the codes. Both inpatients and outpatients are eligible for health and behavior services as Medicare covers the codes in all settings.

Beginnings of Coverage under Medicaid

In the past year, Colorado and Vermont have begun reimbursing for health and behavior services through their State Medicaid plans. Because the initial spending is taken from general revenues in each State, Medicaid often fluctuates with the economy. The past two years have been financially difficult for many States and as a result Medicaid has seen significant cuts. Nevertheless, we will continue to work with psychologists and the SPAs to advocate for inclusion of services under the codes. We are hopeful that as the economy improves the States will be more receptive to learning about the benefits, including the potential cost savings, of using health and behavior services to address patients’ physical health problems.

The Private Insurance Market

Over the past year APAPO has looked to increase coverage of the codes by private insurance. This task is more difficult for several reasons. Because the Federal government does not regulate private insurance, there is no central authority to mandate coverage nationwide. In addition, insurance policies are private contracts, usually between the carrier and an employer or an individual. Since APAPO is not a party to these contracts, the carriers are under no obligation to engage in a dialogue with us about their practices. It is because of these obstacles that we are working with individual psychologists and the SPAs to raise the coverage issue with carriers in their geographic areas.

Psychologists are well positioned to advocate to the carriers because they play an important role as providers of service under the carriers’ policies and can best articulate the needs of their patients. Over the past year we have teamed with psychologists across the country to educate private carriers about the codes. In the spring of 2003, only one private carrier, Carefirst Blue Cross / Blue Shield in the Washington, DC area, was known to be paying for health and behavior services. Since then individual members have actively pursued coverage from private carriers, utilizing material provided by APAPO. When psychologists have been denied reimbursement after billing the codes, we have corresponded with the carriers on their behalf. Thanks to the efforts of individual psychologists, the following private carriers are now reimbursing claims in certain geographic areas:

Aetna

Blue Cross/Blue Shield of North Carolina

CIGNA

Fortis

Mid-Atlantic Medical Services, Inc (MAMSI) — the Washington, DC area

Mutual of Omaha

Nationwide Mutual

RISKCO — under the Virginia workers compensation program

WPPA — Wichita, KS

The Next Steps in Expanding Coverage of the Codes

The ultimate goal is to have the health and behavior codes recognized by all public and private payers. While much has been accomplished over the past two years with Medicare, we realize that acceptance of the codes by private insurance is critical for both psychologists and their patients. Having psychologists submit claims for the codes and follow up with the carriers if denied reimbursement have been important first steps in a process that has resulted in slow but steady improvement in private insurance coverage. Patients with employment-based health care plans can also play an important role by asking their Human Resources office to pursue coverage under the codes. Because health and behavior services can help patients keep physical health problems from deteriorating, they may reduce the need for more drastic, invasive, and costly procedures. This is clearly advantageous to employers who are finding it increasingly difficult to meet spiraling health care costs.

APAPO is currently teaming with psychologists and SPAs who have expressed an interest in pursuing private insurance coverage in their geographic areas. This will be a laddered strategy of advocacy to the carriers with initial requests for coverage coming from the psychologists. Interested members and/or the SPAs will pursue denied claims and refusals to include the codes in the carriers’ plans. APAPO will provide materials for educating the carriers and will become directly involved when appropriate.

We will provide new information on the status of this project as our work progresses. Meanwhile, anyone with questions about the codes may contact the Government Relations office at (202) 336-5889.